Some patients are not notified of abnormal test results

Primary care clinicians and their staff appear to fail to inform some patients, or to fail to document informing patients, about abnormal results on outpatient medical tests, according to a report in the June 22 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.

“Ordering and following up on outpatient laboratory and imaging tests consumes large amounts of physician time and is important in the diagnostic process,” the authors write as background information in the article. “Diagnostic errors are the most frequent cause of malpractice claims in the United States; testing-related mistakes can lead to serious diagnostic errors. There are many steps in the testing process, which extends from ordering a test to providing appropriate follow-up; an error in any one of these steps can have lethal consequences.”

Lawrence P. Casalino, M.D., Ph.D., of Weill Cornell Medical College, New York, and colleagues reviewed the medical records of 5,434 randomly selected patients age 50 to 69 years in 23 primary care practices (19 community-based and four affiliated with academic medical centers). The researchers identified individuals with a clinically significantly abnormal result on one of 11 blood tests or three screening tests commonly performed on an outpatient basis. These patients’ records were then assessed for an indication that he or she had been informed about the abnormal result. In cases for which there was no evidence such communication occurred, physicians were sent a form alerting them to the apparent oversight and giving them the opportunity to correct the record if the patient had been informed or to inform the patient at that time.

In addition, physicians responded to a six-question survey about the processes for managing test results at their practices and their satisfaction with these processes. Reviewers calculated a score ranging from zero to five for each practice, with five indicating that they closely followed five processes derived from the medical literature — routing results to the responsible physician, having the physician sign off on the results, informing the patient of all results (normal and abnormal, at least in general terms) and asking patients to call after a certain time period if they had not been notified of the results.

The reviewers identified 1,889 abnormal test results and 135 apparent failures to inform the patient or to document informing the patient — a rate of 7.1 percent, or about one of every 14 tests. The average process score was 3.8; most practices did not use all five of the basic processes suggested in the literature and most did not have explicit rules for notifying patients of results. “Failure rates varied widely among practices, from 0 percent to 26 percent; practices that used better processes to manage results had lower failure rates and had physicians who were more satisfied with the processes used,” the authors write.

Practices that used a combination of paper and electronic records — a so-called partial electronic medical record?had the highest failure rates, whereas there was no significant difference between practices that used complete electronic medical records or paper records.

“Some elements of medical care (e.g., diagnosis) are an art as well as a science, depend heavily on the cognitive skills and effort of individual physicians, involve much uncertainty and will probably always have relatively high error rates,” the authors conclude. “However, notifying patients of test results does not appear to be such a process; with appropriate within-practice systems, low rates of failure to inform should be possible.”

(Arch Intern Med. 2009;169[12]:1123-1129. Available pre-embargo to the media at www.jamamedia.org.)

Editor’s Note: Funding for this project was provided by the California HealthCare Foundation. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

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